GW1-2022-06281_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
I.Well Contractor Information:
Daniel C.VOW
we0ConuacwrName FROM I TO I}3DFSCMMON 15 _
4 fL 28 ft. ,a —w
NCWC 4368 A ft. ft.NC Well ConhactorCettifi e catiunNumb usWtteas�,*e>b Dk'ZrlDStt d .'. � s.;�,=;45:` GA§rNG fair.
Maupin Well Drilling FROM To DIAMETER THICKNESS MATERIAL
CompanyNanre
+ & 20 ft- t 1/4 In. p1200 pye
t ,
376336 Paz iz.CAsnvGweTU'BING -- .eloreil=l ;_ ..
2.Well Construction Permit#: FROM TO I OMME1Fdt ITHICItNPSS MATQHAL
List all applicable well construction permits#e.(AC,County,State,Vanance,etc.) R ft. bL
3.Well Use(check well no): ft. ft. In.
Water Supply Well: >.17.'SCIEEpIV
FROM TO DIAMETER SLOTSUZ 1 TKK 3[NM MATERIAL
Agricultural 13Municipal/Pubhc 20 ti a n. 11/4 in. 010 sch40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) It. p in. pp
Industrial/Commercial Residential Water Supply(shared) I
Irrigation FROM I TO _ MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water supply Welk + ft. 20 D- nolWug yra�ay
Monitoring Diteovm IL ff.
Injection Well:
Aquifer
q ' Recharge �Groundwate Remediation
Aquifer Store and Recovery Salini Barrie �9.'SA'
q erY tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 20 ft. 28 fL to sand I gravity
Experimental Technology Subsidence control fL fi.
Geothermal(Closed Loop) Tracer 20: G LOG*flach`i1A&lodaf sliAets If' n
Geothermal(Hera' Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION rntur,banimss,mlv oa tyin
de
+ ft. 4 f. gmayday
4.Date Well(s)Completed:3 June 22 WcU 1D# 4 ft. 28 ft. yellow sand
5a.Well Location: ft It
Arlene Caro & ft y�y
Facility/Owner Name Facility ID#(if applicable) ft. & F-0 p
112 NewBenn Dr It. ft.
Physical Address,City,and Zip ft. ft.
Knotts Island 27950eel;, FJF4
County Parcel Identification No.(PIN)
M�i VVtL99+ 1 VtVli i
5b.Latitude and longitude in degmes/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
cation:
N -76.06878
( r�22
6.Is(are)the weu(s)OPermament or (3Tempo—y Signature of n
By 4�or I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 1314o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner,
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: +1 (fL) 24s. For Au Wells: Submit this form within 30 days-of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2®100) construction to the following
10.Static water level below top of casing:5 01.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+^ 1617 Mall Service Center,Raleigh,NC 27699-1617
I Borehole diameter.4 7/8 (in.) 24b.For Injection Wens: In addition to sending the form to the address in 24a
12.Well construction method: mud rotary above,also submit one copy of this form within'30 days of completion of well
(Le.auger,may.cable,direct lush, ) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mau Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 15 Method of test:pacer pump 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: hyporehrtte Amount: 2 oZ completion of.well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resowces Revised 2-22-2016

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